Fraud and Waste Investigator

🔥 0 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $65k - $88.6k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Conduct investigations of allegations of fraudulent and abusive practices • Collaborate on investigations with local, state, and federal law enforcement authorities • Assemble evidence and documentation to support successful adjudication where appropriate • Conduct on-site audits of provider records to ensure appropriateness of billing practices • Prepare investigative and audit reports • Influence department strategy • Make decisions regarding technical approaches for project components • Determine objectives and approaches to assignments with considerable latitude • Speak with members, providers, and industry colleagues • Engage with Humana Legal and outside counsel, Internal Compliance, market areas, clinical teams, business areas across Medicare, Medicaid, and Commercial product lines, and industry trend areas

🎯 Requirements

• Bachelor's degree or equivalent experience • Strong clinical experience across multiple practice areas • At least 2 years of healthcare fraud investigations and auditing experience • Knowledge of healthcare payment methodologies • Strong organizational, interpersonal, and communication skills • Ability to analyze data to metrics • Computer literacy, including MS Word, Excel, and Access • Strong personal and professional ethics • Self-starter and organized • Interview skills and ability to conduct thorough investigations while maintaining compliance with Humana and governmental requirements • Ability to collaborate with internal and external partners, including law enforcement, Legal, and Compliance • Comfort with data analysis using Excel, Access, and PowerBI • Report writing and presentation creation using PowerPoint or another platform • Investigative research and medical record review experience • CPT code experience • Experience testifying in court • Ability to work from a dedicated space without ongoing interruptions to protect PHI/HIPAA information • Self-provided home internet with minimum download speed of 25 Mbps and upload speed of 10 Mbps • Preferred: Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) • Preferred: Understanding of the healthcare industry, claims processing, and investigative process development • Preferred: Experience in a corporate environment and understanding of business operations

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Personal wellness and smart healthcare decision support • Occasional travel to Humana offices for training or meetings